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- Address for Correspondence: Shawn W. Luby
, University of North Carolina, sluby{at}med.unc.edu
ABSTRACT
Simulation in medical education is well documented as an effective educational approach for increasing student engagement and expanding understanding of professional practice. For medical laboratory science (MLS) students, simulation-based laboratories offer a structured opportunity to engage with the preanalytical, analytical, and postanalytical phases of laboratory testing prior to entering clinical rotations. This study evaluates the impact of a novel clinical laboratory simulation experience, Designing and Operating a Clinical Laboratory, on MLS student confidence and comprehension of clinical laboratory operations and communications. Impact of the simulation was assessed by evaluating student confidence in performing key functions required of medical laboratory professionals. Participants completed a pre- and postsimulation questionnaire consisting of Likert-scale items and open-ended questions. Our findings demonstrate consistent increases in confidence across multiple phases of laboratory testing following participation in the simulation. Additionally, participants were asked to rate the effectiveness of the simulation, with responses indicating high levels of satisfaction in, and perceived value of, the exercise. Finally, we describe the design, development, and facilitation of this educational simulation to support replication and further research in this important field of study.
- ALT - alanine aminotransferase
- AMR - analytical measurement range
- CLS - clinical laboratory science
- MLS - medical laboratory science
- SBT - simulation-based training
- SOP - standard operating procedure
- TAT - turnaround time
- UNC - University of North Carolina
- UNC-IRB - UNC institutional review board
INTRODUCTION
Simulation training has been widely recognized for its positive impact on the professional development of students in medical education programs.1 Benefits of simulation-based training (SBT) include increase in learner confidence, interprofessional awareness, and improvement when performing occupational and other task-based practices.2–4 Medical laboratory science (MLS) students also benefit from SBT in both laboratory-focused and interprofessional practice.5–7
A need for increased and robust reporting on SBT in medical laboratory education has been identified in the literature.8 In response, a framework informed by the International Nursing Association for Clinical Simulation and Learning Standard of Best Practice was proposed to support medical laboratory educators in the development, implementation, evaluation, and documentation of MLS simulations.8,9 Guided by this framework, we aim to contribute to this important area of scholarship by reporting on the design, execution, and outcomes of our novel simulation-based student exercise, Designing and Operating a Clinical Laboratory.
METHODS AND MATERIALS
General Course and Simulation Development
In the spring of 2023, clinical laboratory science (CLS) faculty at the University of North Carolina (UNC) began exploring the development of a simulation exercise for the required course, Clinical Chemistry Laboratory. Rooted in our collective 15+ years of experience working as medical laboratory scientists in core laboratory settings, we aimed to develop a laboratory experience that would reasonably simulate a generalist laboratory while working within the manual testing capacities of our student laboratory space. Our focus was to create a standardized introduction to clinical workflow, laboratory communications, and management of collection and specimen issues while providing an opportunity for students to work collaboratively in a supervised environment, all prior to beginning their clinical rotations.
Assays were selected from previous student laboratory exercises and included testing in areas of transfusion medicine, urinalysis, hematology, and general chemistry. In alignment with the National Accrediting Agency for Clinical Laboratory Science guidelines for incorporating preanalytical, analytical, and postanalytical testing phases in CLS curriculum, objectives were developed to address laboratory design, operations, and key functions performed by medical laboratory scientists in a clinical environment.10
The 2-day simulation, Designing and Operating a Clinical Laboratory, took place at the end of the Spring 2024 semester, following the completion of 7 clinical chemistry laboratory exercises. The 7 exercises covered method validation topics including linearity, sensitivity, interference, bias, and method comparison. Multiple manual chemistry assays were used to explore these topics throughout the semester, including total protein, glucose oxidase, and enzymatic alanine aminotransferase (ALT). In addition to examining testing methods, the students also determined unknown patient values, all using prealiquoted specimens.
Simulation Setup and Schedule
At the start of each simulation day, students attended a presimulation briefing (faculty led) covering the simulation in general and the objectives for the simulation (Table 1). Additional briefing topics covered the parameters of the simulation, including influences on laboratory design, personnel requirements, specimen handling, procedures, and documentation. A timeline for the simulation activity is presented in Table 2. The students also received an additional set of documents required for the simulation activities of the day (Table 3). Additional labels provided to students identified specimen processing and specimen storage locations (Table 4).
Learning objectives for Designing and Operating a Clinical Laboratory
Timeline of simulation activity
Issued documents required for Designing and Operating a Clinical Laboratory
Bench labels for specimen processing/specimen storage
Specimen Preparation
Students received specimens and test orders for 5 patients. A combination of deidentified patient specimens provided by our primary clinical affiliate and faculty-developed specimens were used in the simulation. Students performed approximately 35 assays, including quality control, duplicate testing, and dilutions. Collectively, the delivered specimens included results that were greater than the analytical measurement range (AMR) of an assay, collection errors, and critical values, all of which required student intervention and communication with a clinician. For the purposes of this simulation, CLS faculty assumed the role of a clinician receiving and documenting laboratory communications. A list of assays, assay frequency, and specimen preparation is presented in Table 5.
Patient test orders, frequency, and specimen type
Study Population
Twenty-one students participated in the simulation exercise and completed the presimulation survey. Twenty students completed the postsimulation survey. Participants were all CLS students in the CLS division within the Department of Health Sciences at the UNC-Chapel Hill School of Medicine. All participants were in their second semester of UNC-CLS courses and had completed all required laboratory exercises in the required course, Clinical Chemistry Laboratory.
Participation in the simulation was a required activity for all students enrolled in the course. Participation in the evaluation of the activity was anonymous and voluntary. Students were invited to participate in the simulation evaluation (pre- and postsurvey) during 2 separate morning lectures. A facilitator read a preapproved recruitment script, providing the description of the simulation and study design, and then displayed a QR code and web address linked to the survey. Students were informed of the voluntary and anonymous nature of the study and were then invited to use a mobile device or laptop to access the web-based (Qualtrics) survey instrument. In order to ensure anonymity, all students were allowed to access their electronic devices, regardless of survey participation, for 15 minutes, which corresponded to the time that was allotted for survey participation. The study was deemed exempt by the UNC Institutional Review Board (UNC-IRB).
Study Design/Evaluation Tools
This study used a pre- and postintervention design strategy to assess confidence levels both before and after participating in the simulation exercise. Using a Likert scale for ranking, students were asked to assess confidence levels in areas of laboratory performance and communication. The postsimulation survey included an additional set of questions assessing the student’s evaluation of the simulation experience. In addition, 2 free-text response questions were included in the postsimulation survey as a method to collect qualitative feedback. Survey questions reflected the simulation objectives and covered preanalytical, analytical, and postanalytical areas of laboratory practice (Table 6).
Pre- and postsimulation survey questions
RESULTS
Student responses before and after simulation were anonymous and unpaired. Confidence levels were measured using a Likert scale and analyzed by comparing mean confidence ratings before and after the simulation. To evaluate the significance of the observed changes, a one-sided Mann–Whitney U-test was performed using SAS version 9.4.11
Following participation in the simulation, students reported a significant increase in confidence levels on 13 of the 15 items assessing their confidence in performing certain clinical tasks and procedures required of medical laboratory scientists (minimum P value <.05). Confidence level comparisons and statistical significance are presented by testing phase: preanalytical (Figure 1), analytical (Figure 2), and postanalytical (Figure 3).
Preanalytical processes: evaluating clinical confidence pre- and postsimulation. Survey questions are shown on the y-axis. Mean values for presimulation (n = 21) are shown in blue, and the postsimulation (n = 20) survey results are in green. Mann–Whitney U-derived P values included on y-axis. CIs: (1) not confident at all, (2) slightly confident; (3) somewhat confident; (4) confident; and (5) very confident.
Analytical processes: evaluating clinical confidence pre- and postsimulation. Survey questions are shown on the y-axis. Mean values for presimulation (n = 21) are shown in blue, and the postsimulation (n = 20) survey results in green. Mann–Whitney U-derived P values included on y-axis. CIs: (1) not confident at all, (2) slightly confident, (3) somewhat confident, (4) confident, (5) very confident.
Post-analytical Processes: Evaluating Clinical Confidence Pre- and Post-simulation. Survey questions are shown on the y axis. Mean values for pre-simulation (n = 21) are shown in blue and the post-simulation (n = 20) survey results in green. Mann-Whitney U derived p values included on y axis. Confidence Intervals: (1) Not confident at all (2) Slightly confident (3) Somewhat confident (4) Confident (5) Very Confident.
The most pronounced increases in confidence level means, with highly significant shifts in reported confidence (P < .0001), were observed in items related to identifying collection errors, performing testing within the stated turnaround time (TAT), identifying specimen issues requiring recollection, and knowing which specimens required aliquoting (P = .0002). Students also reported significant increases in confidence across all items assessing interprofessional interactions, including communicating tests requiring cancellation and critical values (P < .05). In the 2 areas that did not show significant increases in confidence—identifying results greater than AMR and preparing a dilution—students reported high presimulation levels of confidence. These topic areas are covered extensively throughout the course and are a primary focus of quizzes and examinations, which likely explains the preexisting high level of confidence.
In addition to quantitative responses, students provided enthusiastic free-text comments highlighting the simulation as fun, engaging, and educational. One student stated, “It was really helpful in understanding how a lab communicates and how workflow runs on a day-to-day basis in the lab.” Feedback also included constructive suggestions regarding the simulation’s workflow, with several students expressing interest in more patient specimens and additional opportunities for investigation and problem-solving (Table 7). The majority of participants expressed strong agreement with statements identifying the positive value of the simulation experience (Table 8).
Responses to open-ended questions (postsimulation)
Participant evaluation of simulation experience
DISCUSSION
Prior to introducing the simulation, the clinical chemistry laboratory course emphasized individual understanding, execution, and evaluation of clinical assays. Given the importance of mastering these foundational concepts and skills, students generally work independently at their personal analytical bench throughout the semester. The addition of the simulation marked a shift in this approach, offering students the opportunity to engage collaboratively across all phases of laboratory testing while navigating the complexities of clinical workflow and interprofessional interaction. Importantly, the activity took place before students began their clinical rotations, providing an earlier and structured opportunity for exposure to the movement, pacing, and energy required of a medical laboratory scientist in a clinical laboratory setting. The students responded to the simulation with enthusiasm and excitement, which was notable given that it occurred at the end of 2 demanding semesters of MLS coursework.
Preparing for the simulation was a substantial logistical challenge. Developed and facilitated by the 2 authors, it required considerable time to determine facilitation strategies, create a detailed standard operating procedure (SOP) manual for student use, and document internal procedures for specimen preparation. Planning began a year in advance, with most of the work concentrated in the 4 months preceding implementation.
Patient cases were developed based on the manual assays students had already performed during their 2 semesters of coursework. This allowed for the design of focused and effective examples of common clinical scenarios, such as a patient with an elevated blood glucose level and corresponding glucose and ketones in urine. While developing patient and specimen scenarios, several procedural challenges emerged. For example, determining how the students would document specimen receipt, results from analytical testing, and required communications led to the development of supporting materials, including patient order forms, specimen receipt logs, testing logs, and a spreadsheet for recording laboratory results. Ensuring proper use of these materials required the development of daily prebriefing sessions to orient students to the simulation operations and train them on documentation expectations. During the simulation activity, one faculty member was then designated as the point of contact for documentation questions and served as a patient care team representative, receiving patient results, documenting communications related to specimen cancellation, and confirming and recording the communication of critical values.
Specimen preparation for the chemistry assays also posed a unique challenge. We aimed to simulate the experience of receiving an unspun serum separator tube while maintaining control over the expected patient values. To achieve this, faculty delivered unspun specimen collection tubes filled with expired donor blood to the simulation lab, and students then prepared labeled aliquot tubes for testing across multiple analytical benches. The faculty member then served as a liaison during this process, transporting the unspun tubes to the student laboratory centrifuge located in an adjacent lab. The original patient collection tubes were then set aside for the remainder of the simulation, and a previously prepared aliquot containing a faculty-developed serum specimen was returned approximately 10 minutes later to students for distribution and testing within the simulation. We used a variety of control materials and calibrators to create the specimens.
Although the simulation required considerable preparation time and was constrained by the manual testing options available in our student laboratory, it provided a realistic and immersive experience that reinforced both technical competency and the value of teamwork and communication required in clinical laboratory practice. Overall, we believe that Designing and Operating a Clinical Laboratory provides an approachable and adaptable framework for CLS programs seeking to integrate simulations into their curriculum.
Limitations
The small sample size is a limitation of this study. Furthermore, the evaluation focused primarily on student confidence in clinical settings and did not assess gains in cognitive knowledge. In addition, the impact of specific simulation design components, such as decisions related to staffing and bench layout, was not directly measured. Future studies could explore how these elements contribute to participants’ operational awareness and understanding of clinical laboratory practice. Finally, the impact of the simulation on student preparedness during clinical rotations has yet to be evaluated. Future studies will be important to determine whether the increased confidence observed after the simulation translates into enhanced readiness for clinical practice.
ACKNOWLEDGEMENTS
The authors would like to acknowledge the UNC-CLS division chair, Dr Tara Moon, for her support in the development and evaluation of the simulation exercise; UNC’s McLendon Laboratory for providing deidentified patient specimens for the simulation; and UNC’s Odum Institute for providing statistical consultation.
- Received September 24, 2025.
- Accepted September 25, 2025.
American Society for Clinical Laboratory Science
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Keywords
- ALT - alanine aminotransferase
- AMR - analytical measurement range
- CLS - clinical laboratory science
- MLS - medical laboratory science
- SBT - simulation-based training
- SOP - standard operating procedure
- TAT - turnaround time
- UNC - University of North Carolina
- UNC-IRB - UNC institutional review board
- simulation training
- medical laboratory sciences
- medical education
- professional practice